705SIR R. ARMSTRONG-JONES: SUGGESTION IN SOCIAL LIFE.

more severe than ulcer pain and is immediatelyaggravated by food. The frequency of anorexia hasalready been stressed. In some degree the dyspepticresponses even in carcinoma ventiiculi may bedetermined by the physiological habitus of thestomach. I have in the past few months seen twocases of gastric carcinoma with a syndrome almc-,-ttypical of duodenal ulcer. In both cases the patitntswere of the hypersthenic type, broad-ch(stcd and witha wide epigastric angle, and the pylorus itself was notinvolved. Achlorhydria, the development of whichin association with carcinoma of the stomach wasfirst shown by Golding Bind 18 in 1842, is lessconstant in non-obstructive than in obstructive ecarcinoma of the stomach, but it is gEnerallyfound in diffuse carcinoma of the " lea,ther-bottle "type.

I have reserved until the last a discussion ofthe derangements of function which follow uponthe common operation of gastro-jejunostomy forulcer and upon the complications attendantupon it.

REFERENCES.1. Brinton, W. : Diseases of the Stomach, 1st edition, London,

1859, p. 357.2. Allbutt, Sir T. Clifford : Visceral Neuroses (being the

Goulstonian Lectures on Neuralgia of the Stomach andAllied Disorders), London, 1884, p. 5.

3. Moore, F. Craven : in the Practitioner’s Encyclopædia ofMedical Treatment (Langdon Brown and Keogh Murphy),London, 1915.

4. Hurst, A. F. : Brit. Med. Jour., 1920, ii., 499.5. Hurst, A. F. : Quart. Jour. Med., 1914, viii., 300 ; and Brit.

Med. Jour., 1925, i., 145.6. Bell, J. R. : Guy’s Hosp. Reports, 1922, lxxii., 302.7. Ryle, J. A., and Barber, H. W.: THE LANCET, 1920, ii., 1195.8. Ganz, R. N. : Guy’s Hosp. Reports, 1925, lxxv., 51.9. Langley, J. N. : In Schafer’s Text-book of Physiology, 1900,

ii., 621.10. Leb, A. : Münch. Med. Woch., 1924, lxxi., 1527.11. Brown, W. Langdon: Sympathetic Nervous System in

Disease, London, 1923.12. Hunter, D. : Quart. Jour. Med., 1923, xvi., 95.13. Bonar, T. G. D. : Guy’s Hosp. Rep., 1922, lxxii., 400.14. Hurst, A. F. : THE LANCET, 1922, ii., 1369.15. Graham, G. : Quart. Jour. Med., 1910, iv., 315.16. Bennett, T. I. : Brit. Med. Jour., 1923, ii., 275.17. Ryle, J. A. : Ibid., 1923, ii., 274.18. Bird, Golding : London Medical Gazette, 1842, pp. 391 and

426.(To be concluded.)

An AddressON

SUGGESTION IN SOCIAL LIFE.Delivered at St. Bartholomew’s Hospital, under the auspices of

the Guild of Public Pharmacists, on Jan. 15th, 1925,with Lord Stanmore, Treasurer of St. Bartholomew’s

Hospital, in the chair,

BY SIR ROBERT ARMSTRONG-JONES, M.D.,D.Sc., F.R.C.P. LOND.,

CONSULTING PHYSICIAN TO ST. BARTHOLOMEW’S HOSPITAL INPSYCHOLOGICAL MEDICINE ; LORD CHANCELLOR’S VISITORIN LUNACY ; FORMERLY LIEUT.-COL. R.A.M.C. (TEMP.) ;AND CONSULTING PHYSICIAN IN MENTAL DISEASES TO

THE LONDON AND ALDERSHOT COMMANDS.

MY LORD, LADIES, AND GENTLEMEN,—In thefirst place let me express my sincere thanks for thecompliment paid to me in asking me to address theGuild of Pharmacists, comprising, as I understand itdoes, the representative organisation of all pharmacistsholding appointments in H.M.’s Services, as well aspharmacists serving in hospitals, infirmaries, anddispensaries.

It is dim cult adequately to appreciate as theyshould be the necessary qualifications of themodern pharmacist without a feeling of wonder athis efficiency, and it is clear that he, of the future,will have a much more complicated list of subjectsto master than his predecessors have had, and forthis responsible duty he must possess a mind abovethe average order if he is to prove a competentpharmacist. I looked up the meaning of this wordin the new Oxford Dictionary and I find it means onewho prepares and dispenses medicines, pharmacybeing described as a medicinal potion, but I thinkthis meaning too narrow, for let me state here thatthe remedies the pharmacist is called upon to dispenseare by no means the complete and final agents inthe cure of disease ; for the chief and proximateagent is the subtle, elusive, but yet definite powerfulinfluence of one mind upon another—i.e., the powerof suggestion-which in psychology is a mentalprocess by which an idea becomes an act-in otherwords, the transformation of an idea into an act.The remedv is dispensed and taken in the firm faith,belief, and hope of a cure, the idea of recovery andrestoration is believed in, it may be logical or illogical,but through suggestion the idea is apprehendedas the means to secure health, and in this wonderfulinfluence of suggestion the work of the pharmacistplays a considerable part. The value of the pill orthe potion, the tabloid or the tincture is considerably

enhanced by suggestion. The facility with whichsuggestion acts depends greatly upon the fashionor vogue which appertains to things at the particulartime, and we shall see later that imitation plays itspart in the influence of suggestion, and some know-ledge of the mind is therefore necessary in order to

understand how suggestion operates.POPULAItITY OF THE STUDY OF PSYCHOLOGY.

For this reason, and after some deliberation,I decided to take as my subject some aspect of theMind, which is the inner experience relating to thefeelings, to ideas, and to the power we have to react tothese by the efforts of the Will, and I am strengthenedin my decision by the fact that of late there hasbeen a very great interest taken in problems of themind, more especially since the war, and in thedirection of studying mental suggestion. Ordinarilythe term suggestion implies that one idea will recallanother to the mind which has been previouslyassociated with it, but throughout this paper I shalluse suggestion as any idea which is followed byaction, not necessarily when the person is consciousof it and not necessarily an act of the Will or Volition.

Indeed, this result may take place under differentdegrees of consciousness, that is during the wakingperiod, in partial sleep, or during the hypnotic state.It is for such reasons that the study of psychologyhas become so popular, and we probably tend, morethan in the past, to txamine into our own minds,a process called " introspection." We certainlytend more often to iook into other people’s minds,and by the process of ’’ interpretation

" drawinferences and reach conclusions not always toocomplimentary or fair to the objects of our experi-ments. It is not improbable that before long no onewill be permitted to have a banking account unlesshe has satisfied a standard test at some psycho-technical laboratory. At any rate, there has beena revived interest in mental problems, as to howideas have arisen and whither they tend. BB e areanxious to see how our ideas are sorted and arranged,how they combine to form motives, how motivesmay be analysed, and how behaviour and conductare directed and controlled. It is claimed for thisstudy that psychology has already helped to makechild-life interesting, if not fascinating; that thedullest novel can be read with pleasure, and that boreswhen psychologically presented may be transformedinto the most engaging personalities. As to thisadded interest in psychology let me use a simile-

viz., the motor-car. No driver would ever dream ofusing a machine without first finding out somethingabout its mechanism and how it worked. If heneglected this modest preliminary study, several! interesting things might happen ; perhaps the car

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would not start, or if it started perhaps it wouldnot stop, and the driver (or if he carried passengers. ’.he and they) would soon experience thrills, to saythe least; yet, in the study of the Mind many whoclaim to possess one are perfectly heedless about itsmechanism, although the mind is much more compli-cated, and, may I add, more interesting also, than themotor-car. Fortunately for most of us, the humanmind is to a great extent self-acting, but sometimes themind does go wrong; indeed, it is only too surprising,considering it has about 9000 millions of neuronsor nerve-cells in an average brain, that it so seldomgoes wrong; yet when the mind is looked afterand is attended to until it is understood, it is capableof superlative achievements, for it can carry us intogreat positions of power and distinction, and enableus to maintain these in spite of acute competitionfor a place in the sun. The advantages of an

elementary knowledge of psychology are thereforeclear ; it enables each of us to understand our ownmind, and how it works, as also that of our competitor,the practical result being to save us endless troublein the acquisition of knowledge and in iits applicationwhen acquired, although, luckily, many of us do managewithout special study to acquire some knowledge ofthe working of our minds empirically (Glover) and alsoto attain comparative success. When our minds aremanaged rightly and our thoughts are arranged inan orderly and methodical way, we are enabled moreeasily to follow our various occupations, to find morepleasure in our work, to use our leisure more happily,to select the best companions, even a husband or awife. We also learn to control our will-power and so tomake resolution strong and temptation weak. Indeedit is difficult to see how we can advance at all withoutsome knowledge of psychology. Pope maintainedthat the proper study of mankind was man and thatthe chief thing in man was Mind.

ELEMENTARY SENSATIONS.Like the material world which is made up of atoms

and electrons, the mind is also made up of elementarysensations-hearing, sight, taste, smell, and touch.Sensations are the most elementary mental processeswe can experience, and they are incapable of beingfurther split up even by the most persistent intro-spection or examination of our own minds, but puresensations are only possible during earliest infancy,for we soon begin to think not in atoms as it were,but in molecules ; our sensations tend to be associatedtogether and with other things, so that sensationsbecome percepts, which is the next mental processin development and an active one. The varioussensations, therefore, coalesce and merge into a

united whole, giving us the percept-e.g., the bl1tter-cup is not only yellow, it is form, size, touch, andfeeling ; its acrid taste is also " associated " withit, in other words ; it is now a percept and no longera simple sensation of yellow, but we can proceedfurther in our mental evolution and we can recallthe flower in its absence which gives us the image,or the idea of the flower, and we can proceed furtherstill, for we can in imagination group these flowersinto classes or form concepts of them. Such a processas this is abstraction, and is the constructive work ofthe genius who out of different groups of ideasconstructs new combinations, new mechanisms,new plots for stories, poems, pictures, and greatoriginal works of art. We should therefore all tryto cultivate our senses, be precise and accurate inour percepts, form the habit of appreciating clearideas of percepts and group our ideas into concepts,and from these construct new synthetical groups orclasses. Such a study is the high road to a well-developed mentality, to the full realisation of self,and to the final achievement of our ambitions,aspirations, and aims.

IDEAS ANALYSED.It is an ascertained fact in psychology that only

a few of the many ideas experienced or combinedcan be in our mind at any particular moment-i.e.,

can be attended to in the focus of consciousness,because this focus of the attention is a very limitedfield, and if we analyse our own minds at this moment-or now-our ideas would probably come underfive heads :-

1. Impressions of things around us in this great hallwith ts interesting records.

2. Some bodily or other sensation-e.g., from sitting onhard chairs, or in cold corners.

3. Some memories of past events, such as last week’sclever performances here.

4. Some feeling of pleasure, or the reverse.5. Some promptings of the Will, which are either to sit

still and listen, to make some apt or inapt comment, toexpress approval, or to pick up our hats and walk out.

These would be in the focus. All other ideaswould be outside the focus, or threshold of con-sciousness ; they might perhaps be on the vergeof this field in the subconscious mind and liable tobe recalled, for our subconscious minds are the partsout of which ideas are recruited by an effort of theWill; on the other hand, they may be quite inaccessible,because buried in the unconscious mind, which, asstated, we all possess. We know, or our intimatefriends know, that under certain sets of circum-stances we would act in a certain way-that is, ourinherited traditions, our upbringing, education, andsurroundings have already unconsciously formedour " bias," for we each of us has certain leanings,a certain " bias " of which we may not be conscious;yet we realise that it somehow or other unconsciouslyinfluences our tendencies to act. We cannot, there-fore, too highly value the very great importance ofgood traditions-such as we possess here-the goodeducation and good surroundings which togetherunconsciously help to make, in our own profession,what is euphemistically described as the best type ofdoctor-viz., the Bart.’s man. Consequently, Icannot too forcibly demonstrate to you these threelayers of the mind—viz., the conscious, the sub-conscious, and the unconscious mind-upon each ofwhich suggestions can act. The violinist plays, butis not conscious of reading the notes. I walk alonga rough road, and unconsciously avoid obstacles.The organs in our bodies work unconsciously as domost of our reflexes, and if consciousness were ouronly mental life it would indeed be a poor and narrowone.

It is an extraordinary thing, but still a truth,that all ideas in the mind exist in a perfectly chaotic,confused mass, until summoned into order by theattention. They are all struggling together in competi-tion to get into the field of attention, they are allstriving to cross the threshold and to reach thefocus, or as it has been also called, the dome of themind. All ideas tend, if they can, to rise to the topof the dome, which they are more likely to do if theyare linked up with some pleasurable feeling or anemotion, for- we tend to retain happy, thoughts andto cast out or to repress the opposite, hence theimportance of cultivating the happy side of life,for happy suggestions tend to raise and exalt all thevital functions ; they tend to quicken that inherenttendency to the normal which is characteristic of allliving tissues ; that disposition towards health orthat equilibrium which doctors describe as theMs medicatrix naturae and which is always sensitiveto suggestion, good op bad. It is a fact that onceideas get into the dome of the mind, or into the focus ofconsciousness, they become distinct and clear, becausethe attention or the will is fixed upon them, but evenwhen within the dome they cannot be kept there,they soon pass out again to give place to other ideas,andfit is stated that no group of ideas can remainin the focus of attention for more than 30 seconds.

It is because of this constant current of ideas toreach the dome that the Mind has been comparedto a stream, always coming and going, always flowing.Many ideas are too feeble ever to reach the dome,and it is only the emotional tinge-the fear, the hope,the hatred or love, or the pleasurable sensation-

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attached to the idea that secures its arrival into thefocus of consciousness. Ideas are not socialists, theyhate equality ; they are constantly and continuouslycompeting and struggling to reach the dome, andit is clear therefore that a suggestion made to themind with its appropriate feeling may reach thesummit if the feeling attached to it is sufficiently Istrong. An inscription over the entrance into ourschool buildings, " Whatsoever thy hand findeth todo, do it with thy might," is a suitable suggestionto reach the dome, and success depends on thefeeling attached to it and its application.

THE ACT OF REASONING.

Although ideas in the mind, until focused, are

confused and chaotic they nevertheless do tend, oftheir own accord, to assort themselves, but onlyaccording to certain laws ; for instance, those thatare similar tend by their similarity to be groupedtogether-e.g., a cross-Channel passage suggestscertain unpleasant sensations felt on a similar pre-vious trip ; a political meeting suggests disharmony,if not rowdiness, which occurred on a similaroccasion elsewhere; and Harley Street suggests eminentdoctors, for we knew at least one there. Also, thoseideas that have occurred together in point of timetend to be associated by " contiguity "-e.g., pickingprimroses suggests early spring ; an acid and alkalitogether will burst the stoppered phial, and to suggesttheir association is to expect a calamity; to bestopped on a clear road by a policeman when motoringsuggests the question of speed limit, for the eventhas occurred before. We cannot have ideas withoutfeelings, and with them a time element or a likeness toothers, for they must first be judged or cognised, whichis an act of the Reason. In Reasoning we passfrom one judgment to another deductively whenwe reason from general principles to particular cases.It is the work of the Reason to criticise and tocompare ideas, but the Reason is much influencedby the feeling associated with them, in other words,by their affective tone-i.e., whether such ideas bepleasurable or painful.

WILL-POWER.

There is one other element of the Mind beside thefeelings or sensations, and the Reason, which we havenot considered, yet it is the most important of all;indeed, it is the only one that differentiates man fromthe lower animals. This is the Will, the power ofinhibition, of self-control, the power to say " No ! "It is by the exercise of this faculty that man canclaim to rise to a higher sphere of action and conduct.It is the Will that suppresses the passions, that governsthe instincts, and controls the emotions associatedwith our perceptions, ideas, and concepts, and soprevents their exercising an undue influence over ouractions. It is the Will that collects the momentarysense impressions, the fleeting ideas that pass in theflowing stream, of the mind, and it is the Will thatcollects the memory pictures stored up in the braincells and brings them into the focus or the domeof attention. In the whole mental field it is the Willwhich occupies the sole directing position. Forinstance, when preparing this paper I had to fixmy attention, to experience many struggles in orderto exclude distracting ideas, and to prevent my mindfrom wandering into other channels. At times I hadto use a mental effort to keep my attention fixed onmy subject and so complete the task I set myselfto perform. It was a conscious effort, but it wasessential that I should finish my task; and theconscious effort was the measure of my Will-poweror of my volitional exercise. In the opinion ofcompetent psychologists there is still another sourceof action in addition to and apart from the Will, andthat is the ower of suggestion, which arises from anidea within the Mind. The starting point of suggestionis some idea, which may not be apprehended by theconscious mind, but if it is, it then becomes a’ direct " suggestion ; the clergyman in the pulpit

makes a direct exhortation or suggestion to hiscongregation, the surgeon advises an operation, orM. Ooué commands his patient to repeat he is everyday getting better and better ; and when I presenta complicated prescription to the pharmacist it isa case of direct suggestion that I want it dispensed,it is a transformation of an idea into an act, andthe suggestion may be our own from within (auto-suggestion) or through others from without (hetero-suggestion), yet even a hetero-suggestion becomesan auto-suggestion in the end.

" DIRECT " AND " INDIRECT " SUGGESTIONS.As we know, the Will and the Reason exercise an

inhibitive or a controlling power over suggestions :i-t is, indeed, the whole aim of education to controland direct the mind and so to prevent irrelevantsuggestions from intruding upon it. Thus thereis always a struggle between the orderly controlof the Will and the sudden impulse to act onsuggestions. The influence of " direct " suggestionis less powerful than is that of "indirect" sug-gestion which occurs when the mind is at rest orinactive ; indeed, when the mind is’ fully occupiedand engrossed it is difficult to get any direct suggestionsto act, as is recorded of the philosopher whose wifewas about to present him with an addition to theirhappiness, for when the nurse announced, " PleaseSir, it’s a boy," he coolly replied, " Ask him what hewants, I am busy," and later when the nurse calledout, " Your wife is dying, Sir," he replied, " Tellher to wait till I come " ; or as was the case withanother searcher after truth who was equally engrossedin his meditations, when the messenger rushed inwith the alarming news that the house was on fire,he calmly requested the messenger to convey thenews to his wife, as he never interfered in domesticaffairs. These, and stories of men in action beingso overwhelmed with mental excitement as not toknow they were wounded, show that when the Mindis fully absorbed suggestion acts with difficulty,there is no room for distracting thoughts fromwithout ; but when the mental tension is relaxedthe influence of suggestion is exceedingly strong,for the imagination then runs riot, the Will andthe Reason are both suspended, and the Mind is freeto wander in obedience to half-conscious suggestions.In mental states of reverie, " mooning," or abstrac-tion, the mind is in a suggestible state ready for newideas to be presented. Children when playing games arethus suggestible and are being unconsciously mouldedin conduct and character every minute, and thereforegood suggestions by example and precept are mostimportant, which supports the view of the Jesuit,that if he had the care of the child for the first sevenyears, anyone can have it afterwards ; implyingthat unconscious suggestion would by then havebecome so organised that no subsequent influencescould neutralise those from early teaching. Such" indirect " suggestions made in infancy leaveindelible traces on the mind, which is " wax to receiveand marble to retain," and so, impressions of trainingonce received in early life have the quality ofpermanence ; nevertheless, we are unconscious ofthem, as they do not ordinarily reach the consciousmind; but yet, in spite of this, they form the trend ortendency or bias of the individual in later life, and it isupon the indirect influence of early suggestions thatthe permanent conduct depends. The periods justbefore sleep or just before awaking are the mostfavourable to suggestion, as we know ghost storiesare more readily believed in towards the hour of sleep,partly because suggestibility is most marked at theperiod of approaching sleep and partly also becauseof the state of fatigue then felt, when there is lessvigour to resist suggestion. It is claimed thatsuggestions from the mother repeated nightly whilstthe child is being put to sleep must bear good fruitin after life. Sleep is not necessary to suggestibility,it only facilitates it ; as we know to be the case inthe hypnotic state, which is one of artificial sleep.Some of us may have suddenly awaked from sleep

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and felt we had lost -our way in a strange place andwe have got up under the influence of this suggestionand searched for aid ; and it is a fact that some personsunder the influence of suggestion during sleep havebeen able to solve problems that have bewilderedthem when awake. In illness it is the same, andadvantage is then taken of this readiness to receivesuggestions, to create an impression upon the patientby the solemn manner of the doctor, whilst histop hat, and the mysterious and horrid medicine informal bottles help the suggestion of impressiveness.All doctors know the value of suggestion in thetreatment of disease, and a classic case was thatrecorded by Sir James Paget-a name greatly reveredin this school. This patient’s mother who broughther told the great surgeon " She will not walk."The patient said, "I cannot walk " ; but Sir JamesPaget summarised the truth by saying, the fact is" she cannot Will "-i.e., until the weakened will-power was strengthened by belief in the cure, shecould not recover, but would continue helpless untilsuggestion presented the idea of recovery and this,with its emotion, would rouse the latent power intoaction. In the mental out-patient department atthis hospital a paralysed lame girl was at once curedby suggestion.During the war a soldier who had been blind for

months regained his sight at once when the suggestionwas convincingly made to him that he would see.

Many aphonic soldiers and several who were deaf,from functional lesions, were immediately cured, asalso many who were helpless and paralysed ; and ourcase-books have many records of such cures by theinfluence of suggestion. It is useless as well as unkindto tell a person who cannot cross the street, or remainin a closed room, or who believes himself to beparalysed that he can be well if he chooses and thathis malady is an imagined one. He will only concludehis case is not understood and he will go away worsethan he came. He will probably go away also in thefirm belief that his. case is incurable and chronicand that he himself has been regarded as a shammerand a malingerer. No appeal to his conscious reasonwill be of any avail, but suggestive treatment to hissubconscious mind will cure him at once.

" PRESTIGE " SUGGESTION.

The influence of suggestion coming from a greatinstitution of authority such as Bart.’s, with its greattraditions of the past, and the present accumulatedwisdom and knowledge of skilled teachers such as wepossess here, gives to the treatment of the patientsin this hospital what is described as

" prestigesuggestion," and is an undoubted aid to the healingpowers so successfully employed here. It is not onlythe students that are impressed by this, but thephysicians and surgeons must also profit by thesesuggestions. The same kind of influence acts as asource of great power when emanating from high socialrank, or from some great source of mental ability,or some marked physical strength, or from someother great power ; hence the influence of the Deitywhen invoked in the work of spiritual healing, as wehave lately seen, will help considerably by suggestion,and will add to the number and permanence of thecures. My influence will probably disappear whenI have withdrawn, but the influence of the Deitywill remain. States of mind described as " day-dreaming " or

" castle-building in Spain " are half-awake conditions, and thoughts or ideas suggestedto the Mind in these states are accepted as a normalexperience and believed in because there is a partialsuspension of the Reason and the Will, and thereforethere is no voluntary direction to change theseideas in the Mind, which comes to be entirelydominated by them, the more so when there is withthe suggestion a belief and a faith together withan expectant attitude, as in spiritual healing. Thereis here the feeling that the result anticipated must beaccomplished. The attitude of expectancy greatlyintensifies the power of suggestion.

REPETITION.

Another condition favouring the influence of sugges-tion is repetition. George IV. repeated the statementso often that he was present at the Battle of Waterloothat in the end he came to believe it, and no argumentto the contrary would convince him he was in error.An Oxford graduate used to walk regularly in HydePark when the auto-suggestion came to him that heshould knock off people’s top hats. He realised thatit was an unconventional act and was impolitic andwould be mildly resented, but the suggestion was sostrong, relentless, and tyrannical, and it was so

dominating and persistent that he felt it was wrongto resist it, with the result that he was brought tome at Claybury, and his case is probably familiarto many old Bart.’s men. As to dominating ideas,which are extreme cases of auto-suggestion, everyasylum has its kings, queens, peers, and others becausethe ideas suggested are in harmony with their ownmental trends or tendencies, and no persuasion candispossess these persons of their dominant ideas.In insanity the Will and the Reason are no longer ableto command the thoughts, and therefore the Mindcannot judge or compare what is brought before it,whilst in the awakening from hypnotism the spell ofthe suggestion has been withdrawn. Sometimessuggestion is carried too far and the reverse or thecounter-suggestion may be acted upon. Instead ofthe normal response to the stimulus, other stimulicontribute to the response, and the natural responseto the suggestion is inhibited. The opposed onesupset the balance and the opposite of the suggestionoccurs, because the response is not the result of thetotal of relevant stimuli, and so the suggested stimulusis inhibited. We all know the " cussed " fellow whowhen advised to avoid certain foods yet eats to h’sdetriment, or when advised to take a holiday replieshe does not need one. He takes a pride in doing theopposite to what is suggested, and often defies customand ceremony. Such persons obey the " law ofreverse effort," as M. Coue says, and they constituteour eccentrics, oddities, and singularities. Every-body knows that a committee or a board is a mathe-matical paradox : its collective wisdom is known to beless than the total of its individual members, yetwhat security is often erroneously conveyed topossible shareholders by suggest on when a long listof names figure on a prospectus, which wouldotherwise go into the wate-paper basket. The" prestige " suggestion counts for much here.

" CROWD " SUGGESTION.

The crowd suggestion or mass suggestion alsoexercises a great influence upon the mind. Crowdsof people are very impressive, and crowds of nameson a petition often count for much more influencethan would the names separately. Also, witness thegreat power in healing the sick exercised by pilgrim-ages to Lourdes, Sienna, Assisi, and other places wherethere are relics of the saints ; and at Holywell in ourown country; yet the proportion of cures is lessthan 5 per cent.-some say less than 1 per cent.-and if these statistics were set forth as claims forsupport by the London hospitals, they would soon

cease to be supported. You, as pharmacists, know thechanges that fashion and custom have caused throughsuggestion in the use of medicines and therefore indispensing. Formerly the prescriptions that weremost effective were the most nauseous and the mostrepulsive ; the worse the disease the more horrid theremedy. Each disease had its sign, and could only becured by the administration of the remedy withthe corresponding sign ; for instance, certain plantsthat resembled the bodily organs contained theremedies for these by their similarity to them, thelungwort, liverwort, madwort, pilewort were so

prescribed. For epilepsy, 300 years ago, then, asnow, regarded as rarely curable, the best remedywas the dried and powdered remains of a femalemole for a male epileptic, and a male mole for a female,to be taken when the moon was in the sign of Virgo,

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by which " much ease will result." For insanitythe unfailing remedy consisted in injecting the juiceof beet into the nostrils-probably a cure if it couldever be got up there. The plague was treated with alive pigeon cut in two parts and applied to the solesof the feet. The heart of a fowl, the liver of a mole,and the foot of a tortoise were probably the precursors Iof the poly-glandular tabloid and an anticipation ofour present endocrine therapy. To-day the fashion isfor vaccines, serums, and antitoxins, the blood beingregarded as the great battle-field in which proteinsand bacteria are contesting for a victory over globulinsand precipitins-i.e., so long as the life of their hostendured under the treatment.

GESTURES IN MEDICINE. i

It must not be thought that we of to-day are freefrom " gestures " in medicine. Not long since it wassuggested that human beings had in their naturalevolution approached too near to the herbivora,and man’s inside was too long. On the authorityof a great surgeon everyone was advised to have hiscolon exc*,sed and his internal economy short-circuited, again transforming an idea into an act.The suggestion that persons should be divestedof any part of the alimentary tube which had hithertoserved to assimilate his nourishment did not receivea too cordial support and the vogue dropped.Fortunately, a more sensible view of the functions ofthe 32 feet of our inner tube was taken, but a newfashion was initiated-viz., intestinal antisepsis ;and liquid paraffin became a popular remedy ; so

much so, it is stated, that shares in the Persian oilfields rose considerably in price on the Stock Exchange.How long the suggestion of internal lubricants or ofintestinal disinfectants will last, it is not safe topredict : but it is certain that just as poly-pharmacyhas had its day, so these suggestions, together with isandwiches of pancreas and endocrine preparations, imay also have their day, and the treatment of thefuture may more and more tend to rely on common-sense to avoid " the first occasion of sickness," as

the ancient physicians pronounced it, and " to takeaway the evil effects of the same," as was then taught,which is the encouragement of the vis medicatrixitaturce, or of the inherent tendency to get well thatresides in every living tissue. At present some of the" colloids " are having a struggle to keep their placesas fashionable remedies ; but the latest suggestionin treatment is to provide a supply of vitamins,which have never yet been seen or separated by mortalman, yet they are resident in milk, vegetables, andfruit ; and lest they be lost it will probably besuggested that man should once again reside in agarden and have his fruit and vegetables near, andalso that his herd should be milked at his gate so thathe should not lose the vitamins recommended tohim. It must therefore not be assumed that we-of to-day-are free from using suggestions. Theclassic doctor in recent times was a bearded, middle-aged, grave, and pensive figure, sitting-as in LukeFildes’ picture-by the bedside of a sick childand more correctly holding a wooden stethoscopein his hand. To-day such a picture is out ofdate, being replaced either by an attractive lady orby a clean-shaven young man, dressed in tweeds,and holding in his hands not the stethoscope,but the hypodermic syringe and an ampoule, theup-to-date young physician duly deliberating howmany cubic centimetres of detoxicated serum

he contemplated injecting into his patient sub-

cutaneously. - . - -.

1 am not certain whether the Freudian cult may Jnot (according to Megaw) have suggested a still laterpicture of the doctor in which symbolism reignssupreme : the wooden stethoscope has now become aphallic emblem ; the patient’s attention is transferredto the analyst, whose position is also " father-confessor," the patient’s mind, body (and estate)having been sublimated without resistance into hispower. This picture may be further adorned bytwo statues erected to represent (Edipus Rex on

one pedestal and the hypothetical Censor on another,both in perpetual conflict over the solution of a

dream which is being dramatically related. Thetheme of this picture is " cherchez la femme"; asubject which has continuously, since the TrojanWar, supplied material for the painter’s canvas,but which of late has suffered an acute revivaleven in medicine.

SUGGESTION IN CLOTHES.

Possibly no suggestion is more powerful than thefashion set by clothes, and especially is this the case inour Western civilisation. Formerly clothes conveyedthe distinction of a class and indicated rank. Theytherefore had to be distinct and striking. In thisway they attracted attention and the clothes wereprobably admired. An old book on medicine, dated1649, laid down as the duty of woman, " to serveGod and to maintain man ; to wear garments thatwere comely and strong-made to preserve healthrather than to adorn the person." To-day things

have changed, and a fashionably-dressed woman isno uncommon sight, for she is bound to attractattention and her clothes generally produce a powerfulsensation, which can only be kept up by originalityof design, and by some special style or new colour.A woman with a fashionable hat from Paris andstylishly dressed-however scantily or

" cobwebby,"or

" feathery " this may be-is much happier and moreself-confident than another who is dressed morehealthily and more comfortably, but less fashionably,yet who is superciliously described by the othersas a dowdy frump. Clothes more than anything elselose their attraction to their fashionable wearers

when they become familiar and when they cease

to produce a new sensation. So great to-day is thetriumph of democracy that there is a marked tendencyfor the general adoption of one fashion by all classes ;the only sign of rank and distinction being shown inthe quality and cost of the material:! selected. Whenclothing indicated occupation, they were voluntarilyworn by such as the clergy and the nursing profession,as also by the representatives of the law. Theseupheld in their garb the high rank and dignity oftheir calling. The costume that indicates occupationtends to be resented to-day by such as are in domesticservice, whilst the railway official, the postman, andthe policeman still retain their distinctive garbs.

FOOD AND THE ARTS.

, The fashion in food has also very considerably

changed in recent periods ; a variety of foods, ratherthan the pièce de resistance, is the fashion to-day.

The influence of suggestion extends even to thearts, as witness the interpretation of the beautifuland the true by the futurist and the cubist, who areextravagant and misguided representatives of theartistic set.

Suggestion plays a greater r6le in our lives than weimagine. It is the basis of imitation and so beginsunconsciously in very early life. Its highest formand probably its most agreeable presentation is in thebest actors on the stage, who pourtray by imitationthe most perfect characters that can be suggested tous-or the reverse.

Low-class cinemas play a great part in suggestingassaults, malicious damage, and theft to the sensitiveminds of young people, who are not criminals butonly eager for adventure. Many instances are

recorded in the daily papers. A youth took a knife

and with it stabbed another boy, and the fatherstated " picture-houses are to blame for the wholething." A Dalston boy witnessed a hanging incident.He went home and repeated the occurrence with afatal result. A boy burgled at Upper Clapton andconfessed to seeing the whole thing done throughout atwhat he called the " public picture gallery," and thereis no possible doubt but that pictures thus presentedexercise through suggestion a marked evil influenceon conduct in the sensitive and impressionable mindsof the young.

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710 DR. H. HENRY AND OTHERS: STREPTOCOCCUS SCARLATINA.

CONCLUSION.

May I conclude by saying that the moral of thispaper is that good suggestions should be made to thechild and the young, as they are then unconsciouslyaccepted by them and thus they tend to form a goodbackground, so that the child may act upon thesuggestions reflected into its mind, and in consequenceits trend or mental bias in after life may tendnaturally and unconsciously towards actions thatshall have a high ethical value.The highest suggestion for conduct is to do what

we ought to do, and moral education consists in creatinga desire for right conduct. A child (as well as mostyoung persons) is essentially governed by feelingand not by reason, therefore its present work shouldbe associated with happiness-which is the " universalquest "-and an endeavour made to suggest altruismor a consideration for the good of others, that restric-tions and rules are made for the general good and notfor the individual only. Positive training is alwaysbetter than negative training; a child or a youth isalways open to tactful suggestions and much helpcan be secured from one successful effort towardsself-control because he is then reassured he has madeone good step in the way of directing his will andcontrolling his desires and thoughts, and so.to supple-ment and strengthen the higher good within him.

I have been permitted to make a suggestion to myaudience, viz., that each may take a special interestin psychology—i.e., in the working of the humanmind. It is a study that will well repay attentioneven in leisure moments.

ON THE TOXIN OF

STREPTOCOCCUS SCARLATINÆ.

BY HERBERT HENRY, M.D.LOND.,AND

F. C. LEWIS, M.R.C.S. ENG.,CITY BACTERIOLOGICAL LABORATORIES, BIRMINGHAM.

With

E. H. R. HARRIES, M.D. LOND.,J. CHALMERS, M.B. ABERD.,

AND

W. M. MACFARLANE, M.B. GLASG.,CITY FEVER HOSPITALS, BIRMINGHAM.

(A Report to the Medical Research Council.)

THE aetiology of scarlet fever is a problem whichhas attracted the attention of bacteriologists over aperiod of many years, and, as research work has

Ideveloped from time to time in various parts of the Iworld, so there have arisen a number of theories inregard to the actual causative factor in the disease.For long, attention has been focused on the r6le ofcertain streptococci in this connexion, but it is onlyvery recently that convincing experimental evidencehas been brought forward in support of the viewthat streptococci have a definitely specific relationshipto the disease.The difficulty which workers in the past have had

in establishing this relationship lies in the fact thatit is not possible to produce in experimental animalsa condition that in any way resembles the pictureof scarlet fever as it occurs in man. Nor, as Hektoen 1

pointed out, had attempts at experimental inocula-tion of human beings with material taken from casesof scarlet fever proved successful till the publishedobservations of Dick and Dick2 in 1923. The firstattempts made by these workers to produce scarletfever in human volunteers were published by themin 1921 and proved to be unsuccessful, probablybecause they used individuals who were actuallyimmune to the disease by reason of their being urbandwellers. In their second series of experiments in

1923,2 acting on the suggestion made by Hektoenthat individuals drawn from rural districts might befound to be more susceptible than town dwellers,the Dicks succeeded in producing one case of typicalscarlet fever out of five volunteers. Each of thesewas inoculated by swabbing the throat and fauceswith the culture of a streptococcus obtained from aninfected wound on the finger of a nurse who developedscarlet fever while attending a case of the disease.With a further series of volunteers the Dicks 4

showed that the culture filtrates they were using atthe time produced no disease, whereas whole culturesdid so, and they concluded from this finding that afiltrable virus could be excluded as a causativefactor in scarlet fever. The same observers 6further demonstrated that the streptococci whichare associated with scarlet fever produce a solubletoxin, and that this, when inoculated into susceptiblevolunteers in suitable doses, is capable of giving riseto all the characteristic signs and symptoms of thedisease. Moreover, weak solutions of the toxin S

when injected intradermally-in much the same wayas diphtheria toxin is used for the Schick test indiphtheria-produce in susceptible individuals a skinreaction which provides an empirical measure ofsusceptibility to scarlet fever. Of persons who hadnot suffered from scarlet fever 41’6 per cent. gavepositive reactions, while negative or only faintlypositive reactions were to be found in convalescentscarlet fever cases. This reaction is known as theDick test. The results of the Dicks have been con-firmed by other American workers, notably byZingher. IThe work embodied in the present report repre-

sents an investigation of the toxin of Streptococcussearlatince, more particularly with reference to thebest methods of preparing it, and special attentionhas been devoted to the preparation of stable productsby means of precipitation. These latter, we believe,represent the first step towards a successful measureof the toxin, and so offer a method of approach to astandard Dick test.Our experiments are still actively in progress,

but we believe it to be desirable at this juncture toput forward certain of our findings.

The Dick Test.The Dick test consists in the intradermal inocula-

tion of suitable dilutions of the toxin of Streptococcusscarlatince. The amount of inoculum consists of0-1 c.cm. or 0-2 c.cm. A positive reaction indicates thatthe individual is presumably susceptible to scarletfever, while a negative reaction yields evidence thatthe individual is immune to the disease. A positivereaction begins to appear within a few hours, usuallyfour to six, after inoculation, and reaches its maximaldevelopment in about 24 hours. It is representedby a local area of redness, varying in size and inintensity of colour. This area has, as a rule, well-defined margins, but it may at times merge graduallyinto the surrounding skin. Where the reaction isintense in character it is accompanied by induration.At 48 hours from the time of inoculation most Dickreactions have disappeared completely or have fadedconsiderably, while in the case of strong reactionsthere may be a residual pigmentation and peeling.It may be said, therefore, that the Dick reactiondiffers from the Schick reaction in that it appearsrapidly, lasts for a short time, and then disappearsleaving little or no trace behind.

In all cases it is necessary when testing Dick toxinto use a control. For this purpose we have hadrecourse to the same toxin heated to boiling forone to one and a half hours, as recommended byZingher. In practice it is convenient to inoculatethe toxin to be tested into the skin on the anterioraspect of one forearm, and to inoculate the heatedcontrol into a corresponding area on the other arm.Areas of redness measuring 1-0 cm. or more in diameterare interpreted as positive, while areas of lesser sizeare to be classified as faintly positive. Where thecontrol shows no reaction there is no difficulty in